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Chapter 30 • Local Parastomal Hernia Repair 375
Figure 30-7 Figure 30-8
Suture repair
Mesh
A
Suture repair
Suprafascia mesh
Bowel
Skin
Fat
Space
Fascia
Muscle
Peritoneum and
posterior rectus
fascia
Submuscular mesh
Skin
Fat
Space
Fascia
Muscle
B
Figure 30-9A-B
Mesh
Peritoneum and
posterior rectus
fascia
Figure 30-10
Step 1: Clinical Anatomy
C H A P T E R
31
Small Bowel
Strictureplasty
Steven R. Hunt
The anatomy relating to a strictureplasty is straightforward. Most strictureplasties are performed
in the small intestine. There is no clear transition point between the jejunum and ileum, and
treatment is not differentiated based on this designation. Generally, the ileum has more fat in
the mesentery and more complex arterial arcades with less distinct terminal vasa recta in the
mesentery.
A noteworthy structure is the ligament of Treitz, which is the point where the jejunum
emerges from the transverse colon mesentery. Generally, measurement of small bowel length is
begun at the ligament of Treitz. A second important landmark is the fold of Treves (or ligament
of Treves). On the terminal ileum at the ileocecal junction, this antimesenteric fat fold is the
only nonmesenteric fat over the course of the entire small bowel.
Step 2: Preoperative Considerations
Strictureplasty was developed for the treatment of strictures of the small intestine related to
Crohn’s disease. The technique allows small bowel length to be preserved and allows patients
to avoid short bowel syndrome. A strictureplasty may be performed alone, in series with multiple other strictureplasties, or in combination with resection.
Laparoscopy is not an option for patients who are identified preoperatively to need a strictureplasty. Generally, the thickened and shortened mesentery of diseased small bowel does not
lend itself to delivery through a small incision. Additionally, strictureplasty techniques require
a significant amount of palpation, and performing a strictureplasty with straight laparoscopy is
not recommended.
Preoperative imaging studies include computed tomography, magnetic resonance enterography, small bowel follow-through studies, or a barium enema. These studies should be done as
needed to delineate the relevant anatomy and to rule out active inflammation.
Strictureplasty is best performed on chronic fibrotic strictures. If a phlegmon or abscess is
present, the patient should be given ample time to allow for the inflammation to resolve, or
resection should be planned.
376
Chapter 31 • Small Bowel Strictureplasty 377
Strictureplasty for Crohn’s disease should be considered in patients with multiple strictures
and patients who have had multiple previous small bowel resections in whom repeat resection
could lead to short bowel syndrome. It is best to avoid strictureplasty in the following
situations:
s Localized perforation or phlegmon
s Fistula
s Multiple strictures over a short segment of small bowel
s A stricture near the site of a planned resection
s Radiation strictures
s Colonic strictures
s Malnutrition
As with other small bowel procedures, there is no need for a bowel preparation. Broadspectrum antibiotics and deep vein thrombosis prophylaxis should be administered preoperatively. Provided that there is no colonic disease and no need for access to the rectum, these
procedures can be done in the supine position.
Step 3: Operative Steps
u
The length of the stricture determines the appropriate type of strictureplasty. For shorter
strictures (<10 cm), a Heineke-Mikulicz strictureplasty should be performed. For strictures
longer than 10 cm, a Finney or Jaboulay strictureplasty should be performed. In the unusual
case where a stricture is longer than 20 to 25 cm, a divided side-to-side isoperistaltic strictureplasty can be performed. Each of these procedures is described separately.
378 Chapter 31 • Small Bowel Strictureplasty
Heineke-Mikulicz Strictureplasty
u
After a stricture has been identified as appropriate for a Heineke-Mikulicz strictureplasty, two
stay sutures should be placed on each side of the antimesenteric edge of the small bowel at
the midpoint of the stricture. A longitudinal incision should be created on the antimesenteric
side of the small bowel (Figure 31-1). The incision is made with the electrocautery. The incision should begin 2 cm proximal to the stricture. The incision is initially made through
normal small bowel proximal to the stricture. A tonsil clamp can be used to guide the remainder of the longitudinal enterotomy over the entire length of the stricture and 2 cm out onto
normal bowel at the distal end of the stricture.
u
Tension is placed on the stay sutures at the midpoint of the longitudinal incision (Figure
31-2). A central suture is placed across the central portion of this transverse closure at each
point of the apices of the initial incision. The suture is tightened down to show that the
transverse closure of this strictureplasty is possible. If this central suture can be tied down
without significant tension, it is appropriate to proceed with closure.
u
The incision is closed transversely with an absorbable suture (Figure 31-3), starting at each
stay suture and proceeding to the middle of the transverse opening (Figure 31-4). The choice
of simple interrupted sutures, as opposed to a running inverted baseball stitch suture line,
is left to the discretion of the surgeon. There are no data to support one technique over the
other. A single-layer closure is usually adequate (Figure 31-4). Oversewing the thickened
bowel with Lembert sutures can be quite difficult and can result in further narrowing of the
strictureplasty, defeating the purpose of the procedure.
u
As an alternative to single-layer closure, the transverse closure can be bolstered with wide
bites of simple interrupted absorbable sutures across this transverse closure suture line.
u
An endoscopic biopsy forceps should be used to capture a portion of the mesenteric surface
(usually an ulcer is present) at the center of the stricture to screen for cancer, or a shave
biopsy can be obtained from the antimesenteric cut surface.
Finney (Jaboulay) Strictureplasty
u
The Finney strictureplasty is appropriate for strictures 10 to 20 cm long. These strictures
generally are not suitable for Heineke-Mikulicz closure because it is difficult to bring the
midpoint of the transverse closure of such a strictureplasty into approximation.
u
To begin this strictureplasty, the bowel should be folded into a “U” configuration with either
end of the stricture as the apex of the “U” (Figure 31-5). A single stay suture should be placed
at the apex of the “U” and at the top of the arms of the “U” on normal bowel to maintain the
bowel in this “U” configuration.
u
An antimesenteric incision should be made 2 cm out onto normal bowel, beyond the stricture
and the same length on the normal limb of the “U.”
u
An absorbable suture is used in a running fashion to complete the strictureplasty. The initial
suture is started at the folded edge of the back walls of the strictureplasty. The simple suture
line is sewn down to and around the corner bringing the two limbs together. A second
running suture should be started on the antimesenteric surface at the apex of the “U” and
sewn in a running fashion along the anterior wall to meet the other suture and complete the
closure of the newly enlarged lumen (Figure 31-6).
Chapter 31 • Small Bowel Strictureplasty 379
Figure 31-1
Figure 31-3 Figure 31-4
Figure 31-2
Figure 31-5 Figure 31-6
380 Chapter 31 • Small Bowel Strictureplasty
Side-to-Side Isoperistaltic Strictureplasty
u
For strictures longer than 20 to 25 cm, the entire length of the stricture should be elevated
into the wound to display the mesentery. The bowel at the midpoint of the stricture should
be divided transversely with the electrocautery. The mesentery to this bowel should be divided
in a perpendicular fashion to preserve blood flow to both ends of the bowel.
u
After the mesentery is divided, the proximal limb of the diseased bowel is overlapped with
the distal limb of bowel. On each end, the diseased bowel should overlap the normal bowel
by at least 2 cm. These two limbs of bowel are laid side by side.
u
An outer row of simple interrupted Lembert stay sutures is placed along the mesenteric edge
to approximate and hold the two limbs. After this suture line is placed, each limb of the
bowel is opened longitudinally on the antimesenteric border. The incision should extend out
onto the normal small bowel, proximally and distally, to accommodate for the overlapping
diseased segment. The ends of each limb are spatulated to facilitate the closure in the corners.
The inner layer of the back row is completed with two running, simple, absorbable sutures,
each starting at the midpoint of the back row. The sutures are continued around each corner
and across the anterior closure until they meet and are tied to each other. A second layer of
simple interrupted sutures is placed to reinforce the anterior closure line.
u
Small titanium vascular clips should be placed at the mesenteric border of the middle of each
strictureplasty site to act at the ends of the stricture as a marker to identify each site (by the
number or pattern of clips at each site).
Step 4: Postoperative Care
Patients should be maintained on intravenous fluids until they can resume adequate oral intake.
Patients who require multiple strictures at a single operation should be decompressed with a
nasogastric tube until resolution of ileus is documented. Otherwise, patients are begun on a
liquid diet on postoperative day 1, and the diet is advanced as tolerated. Patients are discharged
only when they show adequate bowel function and can tolerate a regular diet. Prophylactic
antibiotics are continued for a total coverage period of 24 hours. Deep vein thrombosis prophylaxis is continued until discharge with either pneumatic compression boots or subcutaneous
heparin. Patients are ambulated on postoperative day 1, and the Foley catheter is removed as
soon as the patient is ambulatory.
Step 5: Pearls and Pitfalls
Hemorrhage is a common complication after a strictureplasty. It usually manifests as gastrointestinal bleeding and results from hypervascularity of the cut edge of the bowel involved in the
Chapter 31 • Small Bowel Strictureplasty 381
strictureplasty. The hemorrhage usually can be treated with supportive care including correction
of coagulopathy, serial hemoglobin determinations, and transfusion as appropriate. In refractory
cases, hemorrhage may be treated angiographically. The titanium clips placed at the time of the
initial strictureplasty can facilitate the identification of the bleeding sites. If embolization fails,
patients may need to return to the operating room. An enteric leak may occur at the site of the
strictureplasty. If the leak is contained, it is best treated with radiographically guided drainage.
If there is free leakage of enteric contents in the peritoneal cavity, re-exploration is necessary.
It is often difficult to determine whether a stricture is symptomatic based on its external
appearance. Generally, bowel that permits the passage of a Foley balloon filled with 3 mL of
saline should not be symptomatic. The presence of “occult” strictures of the small intestine can
be identified using a Foley catheter. At a point where there is a known stricture, after the enterotomy has been made, a Foley catheter with the balloon inflated to 3 cm with saline may be
inserted proximally and distally. The balloon can be withdrawn through the bowel to identify
other points of stricture.
In circumstances where short bowel syndrome is a possibility, it is necessary to measure the
small bowel; this is generally done starting at the ligament of Treitz. A 75-cm umbilical tape is
marched along the bowel to determine the actual length of the bowel. This measurement should
be recorded in the operative note for reference in the future.
Although the incidence is quite low, adenocarcinoma can develop in the small bowel in cases
of chronic active Crohn’s disease. During strictureplasty, biopsy specimens of any suspicious
areas of the small bowel mucosa and the area of ulceration on the mesenteric aspect of the
stricture should be obtained and sent for frozen-section analysis to rule out the presence of an
adenocarcinoma.
Titanium hemoclips should be used to mark the proximal and distal extent of each strictureplasty to allow for radiographic identification in the future. These clips can be useful in cases
where there is postoperative bleeding, cases with a diagnosis of cancer in the biopsy specimen
of the stricture, or when patients develop subsequent strictures to identify the site of the previous strictureplasty.
More recent studies have shown that it is safe to perform strictureplasties across an ileocolic
anastomosis. Depending on the configuration of the stricture and the anastomosis, either a
Heineke-Mikulicz strictureplasty or a Finney strictureplasty may be used.
Selected Readings
Dietz DW, Fazio VW, Laureti S, et al. Strictureplasty in diffuse Crohn’s jejunoileitis: safe and durable. Dis Colon Rectum
2002;45:764–70.
Shatari T, Clark MA, Yamamoto T, et al. Long strictureplasty is as safe and effective as short strictureplasty in small-bowel Crohn’s disease.
Colorectal Dis 2004;6:438–41.
Yamamoto T, Fazio VW, Tekkis PP. Safety and efficacy of strictureplasty for Crohn’s disease: a systematic review and meta-analysis. Dis
Colon Rectum 2007;50:1968–86.
Step 1: Clinical Anatomy
C H A P T E R
32
Resection of Rectorectal
Tumor with Sacrectomy
Anne Y. Lin and James W. Fleshman, Jr.
Pelvic Anatomy
The pelvic anatomy is complex with interrelationships between the rectum, vagina, uterus,
ovaries, bladder, and prostate. The anatomy is important for pelvic dissection because of the
various structures that are at risk, such as the splanchnic nerves (innervation of the bladder
and sexual organs), the ureters, and the organs themselves. The common iliac artery and vein
on each side of the sacral promontory course along the posterior aspect of the pelvic brim. The
hypogastric plexus of parasympathetic and sympathetic nerves is found between the bifurcation
of the aorta and common iliac vessels. This plexus coalesces to the right and left to become the
splanchnic pelvic nerves, which run along the inner aspect of the pelvic side wall to the level
of the obturator fossa and the anterolateral ligaments carrying the middle hemorrhoidal vessels.
Nerve fibers course from the splanchnic nerve to the rectum through the anterolateral ligaments
along the middle hemorrhoidal vessels. These nerves continue to either the vagina or the prostate as the nervi erigentes. A clear understanding of this nerve anatomy is critical because it is
easily damaged during dissection and results in both sexual dysfunction and urinary bladder
dysfunction (Figure 32-1A).
At the level of the sacral promontory, an areolar tissue plane begins behind the superior
hemorrhoidal artery. The superior hemorrhoidal artery descends from the bifurcation of the
inferior mesenteric artery and splits at approximately S1-2 to give two major trunks down the
posterior aspect of the rectum. The mesorectal envelope encases the fat, lymphatic, and vascular
structures to the rectum. The areolar tissue plane outside the mesorectal envelope is known as
the “holy plane” and guides the dissection in the pelvis. A cross-sectional diagram of the pelvis
shows the visceral peritoneum encasing the mesorectum with the areolar tissue plane between
the visceral peritoneum and the parietal peritoneum posteriorly. The parietal peritoneum covers
a nerve and venous plexus over the sacrum and the musculature of the side wall of the pelvis.
Maintaining dissection within the areolar tissue plane between the parietal peritoneum and the
visceral peritoneum protects all of the crucial structures in the pelvis (Figure 32-1B).
382
Chapter 32 • Resection of Rectorectal Tumor with Sacrectomy 383
Inferior
mesenteric
plexus
Rectum
A
Figure 32-1
L2
L1
L3
L4
L5
S1
Spinal cord
Cauda equina
Sacral nerves
Hypogastric
nerve
Nervi erigentes
Presacral (Waldeyer's) fascia
Fascia propria of rectum
Lateral ligament of rectum
Pelvic plexus
B
L5
S2
S3
S4
Sacrum
Rectum
Bladder
Superior hypogastric
plexus at L5
Vessels and nerves
in presacral space
Line of dissection
Nervi erigentes
on lateral wall
Denonvilliers' fascia
Pelvic plexus
anterior to rectum
Anococcygeal
ligament
Ischiorectal
fossa
External anal
sphincter muscle
Ischial tuberosity
Figure 32-2
Coccyx
Lines of dissection
Anus
Levator ani muscle
Perineal body
Vagina
AB
Levator ani muscle
External anal
sphincter muscle
Ischiorectal fossa
CD
384 Chapter 32 • Resection of Rectorectal Tumor with Sacrectomy
The rectum descends through the middle of the pelvis following the curve of the sacrum and
at the level of the coccyx makes a right angle to exit through the pelvic floor via the anal canal.
The levator ani muscles on either side of the pelvic floor form the support diaphragm of the
pelvis and extend up onto the side wall of the pelvis to insert in the ischiospinous ligament
attachments covering the nerves and vessels of the deep pelvic floor. The tip of the coccyx
attaches to the pubococcygeal ligament, which supports the puborectalis muscle as a semicircular sling from the pubis around the back of the rectum. This muscle closes the top of the
anal canal anterior to posterior (Figure 32-2).
The anterior pelvic structures including the bladder, prostate, and vagina are separated from
the rectum by the rectoprostatic or rectovaginal septum. A visceral peritoneal layer known as
Denonvilliers’ fascia is the posterior boundary of the anterior structures. This fascia protects the
seminal vesicles and prostate during dissection. The areolar tissue plane surrounding the fat of
the mesorectum continues around the entire rectum to the anterior surface of the rectum below
the cul-de-sac of the pelvis. The plane is found behind or posterior to Denonvilliers’ fascia. The
anterolateral ligaments of the rectum carry the middle hemorrhoidal vessels into the mesorectal
envelope through the visceral fascia from an anterolateral direction. Dissection and transection
of these middle hemorrhoidal vessels reveals the anterior areolar tissue plane behind Denonvilliers’ fascia, which can be followed all the way down to the anal canal.
The ureters, which have been described as running into the pelvic area over the pelvic brim
crossing the common iliac artery and vein on either side of the pelvis, continue into the pelvis
along the side wall of the pelvis toward the posterior aspect of the bladder. In a nonoperated,
pristine pelvis, the ureters are higher up along the side wall of the pelvis aiming toward the
posterior aspect of the trigone of the bladder. In females, the ureters run between the arterial
blood supply of the uterus along the anterolateral side wall of the pelvis. In males, ureters are
not exposed during the distal pelvic dissection. The ureters may be drawn posteriorly after a
previous operation but are normally fairly well protected anteriorly and laterally. In a previously
operated pelvis, it is always wise to place ureteral stents at the beginning of the procedure to
aid in identification of the aberrantly placed ureters.
Anal Anatomy
The upper anal canal begins at the puborectalis sling or the anorectal ring, which sits at the
level of the pelvic floor and can be palpated through the anal canal as a bulge posteriorly (Figure
32-2). The longitudinal muscles of the rectum continue into the anus as the intersphincteric
plane demarcating the line between autonomic internal sphincter and somatic external sphincter
fibers all the way down to the level of the anal canal skin where the intersphincteric groove is
palpable. The ischiorectal fossa fat is found outside the circular fibers of the external sphincter
that encircle the rectum. The pudendal nerve and vessels traverse the ischiorectal fat from each
ischial spine through Alcock’s canal to the posterolateral aspect of the anal canal. During the
perineal portion of a procedure, the pudendal nerves and vessels must be controlled.
The rectovaginal and rectoprostatic septum descends all the way to the level of the perineum
anteriorly. The transverse perinei muscle separates the anterior and posterior perineum. The
terminal fibers of the longitudinal muscle of the rectum insert into the skin of the anal canal
just outside the anal verge as the corrugator cutanei ani and cause the ridges that are noticed
around the anal canal. The internal sphincter is the hypertrophied circular muscle of the wall
of the rectum. The lowest portion of the internal sphincter can be palpated as a groove where
the longitudinal fibers insert on the skin.